The problem
The Five Whys is the most accessible root cause analysis tool: ask why five times in succession, and you move from observable symptom to fundamental cause. It works on a whiteboard in five minutes for a team of any size. The process is simple enough that it gets used — which is more than can be said for more elaborate analysis frameworks.
The problem is that a Five Whys session on a whiteboard leaves behind a vertical ladder of five or six boxes and arrows. That ladder is the analysis — but it only exists on the whiteboard. The root cause is box five. The corrective action is what you decided to do about box five. Neither survives the room without deliberate capture.
Teams that run Five Whys without documentation repeat the same root causes over and over. An engineering team that fixes the symptom three times before finally looking at the root cause has run three Five Whys sessions in their heads without writing any of them down. The written Five Whys, captured and filed against the specific problem, is what prevents the fourth incident.